Psychopathology

CC

26-year-old white female. Individual is A/O x3. Individual reports she was placed on medication during recent inpatient admission to psychiatric facility. Individual reports “it works a little too well. It makes me sleepy.” She reports originally going to the psychiatric facility because she could not sleep. Individual reports being diagnosed with Bipolar disorder. She reports losing 14 pounds within one week. Individual reports taking Gabapentin 600 mg in the morning, 600 mg at noon, and 1200 mg at night, and Abilify 5 mg at night. Individual complains of sleeping too much at night. Individual rates life 8/10 with 10 being total happiness. She denies S/I, H/I. individual reports that she has highs and lows. She reports she tried Lithium during inpatient admission “I had a really bad reaction. I had diarrhea.” DX; Bipolar I disorder (mixed); Mild depression. Plan; Gabapentin 600 mg tablet, 1.5 tablet nightly, Gabapentin 600 mg one tablet twice daily, Aripiprazole 5 mg one tablet nightly.

Mental function

PHQ-9 total core: 4, GAD-7 total score: 6

Vitals

Ht: 5’11”

Wt: 169 lbs

BMI: 23.57

Pain: 0/10

HPI

“Everything hit me like a freight train in January. I could not sleep.” Individual denies childhood trauma.

PMHx

Bipolar disorder

Hallucinations, delusions – Reports hallucinations and delusions when medications were adjusted.

Hyperlipidemia

PSHx

Comments: teeth pulled; cyst cut in back

FHx

Comments: Mother (living) Father (living), skin cancer (mets to brain)

Soc Hx

Alcohol: do not drink

Drug Abuse: No illicit drugs

Tobacco: Never smoker

Ob Preg Hx

Age of menses: 12

Allergies

No known medication allergies

ROS

Psychiatric: (+) change in mood, (-) depression, (-) sadness interfering with function, (+) anxiety, (+) nervousness, (-) sleep disturbance, (-) suicidal/homicidal ideations, (-) hopelessness, (+) worthlessness, (-) delusions, (-) hallucinations